Burns - Information and Specialists

A burn is tissue damage caused by exposure to heat. The skin is most commonly affected by burns because it acts as a protective layer for the entire body and is therefore most likely to be burned by hot objects (or even the sun). Mucous membranes can also be affected by burns, for example when drinking hot liquids or swallowing hot objects (sword swallowers).

The skin is the largest human organ and typically covers an area of up to two square meters. Depending on the body region and the amount of pressure applied, the skin’s thickness can range from half a millimeter to five millimeters. While it is particularly thick on the soles of the feet and palms of the hands, it can be as thin as paper in other areas. 

The skin consists of two main layers:

1. Cutis
2. Subcutis

The upper layer of the skin is the cutis. This is further divided into the outer epidermis and the underlying dermis, also known as the corium. The lower layer of the skin is called the subcutis and consists of fatty tissue permeated by blood vessels.

A burn is generally a very serious condition that affects not only the skin but the entire body. For this reason, it is often referred to as “burn disease.” The larger the area of burned skin and the deeper the skin damage extends into the tissue, the more severe the resulting burn injury will be. In addition, the skin acts as a heat reservoir, and the full extent of the burn usually becomes fully apparent only after several hours. An example of this is sunburn, where the full extent of the burn often becomes visible and noticeable only in the evening after sun exposure.

The severity of a burn depends on the temperature and the duration of heat exposure. The depth of tissue damage is the decisive factor here. Depending on the degree of damage, medical professionals classify burns as first through fourth degree:

• 1st-degree – The damage is limited to the epidermis; the burn usually heals without complications.
• Second-degree – The burn penetrates into the dermis, and blistering typically occurs. Scarring and pigmentation changes are possible during the healing process.
• Third-degree – The entire epidermis is affected, and the damage extends into the subcutaneous tissue. This often results in damage to the skin’s nerves, which is why patients feel no pain. Although the lack of pain may seem advantageous to the affected person at the time, it is actually indicative of extensive tissue damage. During recovery, the skin forms deep scars, which often require plastic or cosmetic surgery.
• 4th degree – All layers of the skin are charred, and the damage extends to the underlying tissue, including tendons, joints, and bones. This may result in the amputation of the affected body part.

Burn degrees are used for the clinical classification of a burn based on the depth of skin damage @ designua /AdobeStock

What does the so-called Rule of Nines mean?

To estimate the size of a burn, medical professionals use the Rule of Nines. This rule divides the body into areas, each of which accounts for approximately 9 percent—or a multiple thereof (18 percent, 36 percent)—of the total body surface area: 

• Head/neck and each arm: 9 percent each 
• Each leg: 18 percent
• Torso: 36 percent
• 1 percent is accounted for by the palms of the hands and the genital area

If more than 15 percent of the skin surface is burned, the injury is considered life-threatening in adults; in children, as little as 10 percent—or even less—is sufficient. If the burn is accompanied by inhalation trauma, the percentage is halved. 

What is inhalation injury?

Doctors refer to inhalation injury when heat enters the airways through inhalation and causes further burns there. This is most commonly caused by smoke, for example, when it is not immediately possible to escape from a burning house or car. Inhalation injury is a very serious condition that generally requires intensive care monitoring. The lungs are the organ most severely affected; however, burn-related complications also arise here due to the absorption of toxins and impaired lung function following the injury.

Most burns occur in the home or during leisure activities. Only about one in five heat-related skin injuries occurs in the workplace. The causes vary:

• Flames, open fire, explosion (classic burn)
• hot liquids (scalding)
• hot objects (contact burns)
• Concrete or cement, solvents, or cleaning agents (chemical burns)
• Sunlight, radiation treatments involving X-rays and UV rays (radiation burns)
• Electric current, lightning (electrical burns)

How can burns be prevented?

Burns can be easily prevented in everyday life by being more careful. The risk of injury is particularly high for young children. In their eagerness to explore, children can quickly knock hot drinks off the table or open oven doors. Paying special attention and installing safety locks or stove guards can help prevent accidents. Adults should be especially careful when barbecuing.

The symptoms of a burn depend on the degree of the burn. As a general rule, the deeper the injury, the less pain is felt.

• A first-degree burn causes symptoms such as redness, swelling, pain, and a feeling of tightness in the skin.
• Second-degree burns damage both the epidermis and the dermis. The consequences include redness, blistering, a weeping surface, and pain. The deeper and more extensive the burn, the less pain is felt. This is because deep burns also damage the sensory nerve endings that transmit pain. 
• In third-degree burns, all layers of the skin are affected. The wound is charred, ranging from white to black, and dry. The patient feels little or no pain.
• A fourth-degree burn is also referred to as charring. In addition to the skin, bones, muscles, and tendons are affected. The wound is black in color; due to the destruction of the nerve endings, the burn is not associated with pain.

What are the symptoms of burn injury?

Severe burns generally have consequences for the entire body. The patient loses proteins and bodily fluids through the wound, leading to a lack of oxygen and impaired blood circulation. Dizziness or loss of consciousness may occur, as may burn shock. During burn shock, blood pressure drops, the heart beats noticeably fast, the arms and legs become cold and pale, and metabolic disorders occur. In the worst-case scenario, organ failure may result. Inhalation trauma also has a negative impact on the prognosis. Difficulty breathing, hoarseness, or coughing up soot indicate damage to the respiratory tract.

Second-degree burns heal within 1–2 weeks @ lapis2380 /AdobeStock

As with all accidents, proper first aid is of great importance in the case of burns. First, the victim is moved to safety and the source of heat is removed. Clothing that has burned onto the skin should initially be left in place. In the case of severe or extensive burns, the first responder must immediately call emergency medical services. Until help arrives, it is important to keep the injured person warm. Ideally, a rescue blanket should be used as a pad with the silver side facing inward.

1. For a small, first-degree burn, medical attention is usually not required. In this case, hold the wound under cool, running water. However, the temperature should not fall below 20 degrees Celsius, as this could lead to hypothermia. A maximum duration of 20 minutes is recommended. Afterward, cooling gels are applied or compresses are placed on the area. 
2. Second-degree burns with blistering can be shown to a doctor after initial first aid. The doctor will clean the wound and open any blisters under sterile conditions. 
3. Third-degree burns always require a visit to the doctor and, in most cases, even inpatient treatment in a burn unit. There are hospitals specializing in burns (burn centers) for this purpose.
4. In cases of fourth-degree burns or extensive burns (even first-degree), and in cases of suspected or confirmed inhalation injury, an emergency physician should always be contacted due to the risk of circulatory shock.

Patients with deep burns usually face a long road to recovery. After initial wound care, the priority is to prevent infections. Afterward, plastic surgeons take over. The dead skin is removed and replaced with a skin graft. This is preferably taken from healthy areas of the patient’s skin. In particularly severe cases, when bones and joints are also charred, amputation of the affected body part may be necessary.